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APPLICATION FOR PERMIT <br /> 1 t„ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> s/� <br /> Job Address City , Lot Size/40ae,. - PM <br /> Owner's Name, AM �.� Address ��lt� Phone ( PP& <br /> Contract 46_Address 5 /4 izwLicense No. 2„� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Q <br /> Depth :OXFiller Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 2Q0 feet.) <br /> Installation will serve: Residence Commercial_ Other + <br /> Number of living units: Number of ladroo <br /> i <br /> Character of soil to a depth of 3 feet: Water table depth Q <br /> th <br /> SEPTIC TANK LaWf Type/Mfg Capacity MpQQ No. Compartments <br /> PKG. TREATMENT PLT. ❑ f r Method of Disposal <br /> Distance to nearest: Well Foundation �Q Property Line O— <br /> LEACHING LINE C�No. & Length of lines Total length/size Q Y <br /> FILTER BED ❑ Distance to nearest: Well 400 Foundation /Q Property Line -f—f <br /> SEEPAGE PITS Depth a� Size Number <br /> SUMPS ❑ Distance to nearest: Well = Foundation 110 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Con`tractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for required inspections. Complete drawing on reverses e. <br /> Signed Title: Date: ` o d 9 <br /> FOR DEPARTMENT USE ONLY0— <br /> Application Accepted by l / DateAre <br /> IN. or Grout Inspection by Date " t� Final Inspection by '� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE I PERMIT"N0. <br /> + EH13-241REV.1/e5> 4s; - Fv- <br /> EH <br /> 1426 <br /> i <br />